MAIB ferry collision report highlights overreliance on displays
Situational awareness and over reliance on some systems was a factor in the collision of a ferry with a moored yacht and it subsequent grounding a report by the UK’s MAIB has disclosed.
In October 2018, when navigating in severely reduced visibility due to fog in Cowes Harbour, the master of the ro-ro passenger ferry Red Falcon lost orientation when his vessel swung out of control, departed the navigable channel and was spun around through 220°.
In his confusion the master drove the ferry in the wrong direction resulting in a collision with the moored yacht Greylag which was sunk on its mooring as a result. Red Falcon subsequently passed through the yacht moorings and ran aground in soft mud. The ferry was re-floated later that morning having suffered no damage. There were no injuries sustained to passengers or crew, and no pollution. The yacht was a constructive total loss.
After entering Cowes Harbour the visibility had reduced and the helmsman experienced difficulty steering due to the lack of visual references and his lack of practice steering by digital compass alone into Cowes Harbour. This led to the master taking over control and operating the steering and propulsion himself. Critically, the role of keeping an oversight of operations was then lost. The master became fixated upon the information displayed on his electronic chart and operating engine controls, ignored information displayed on other electronic equipment, and became cognitively overloaded due to high stress. His lack of practice using instruments alone to manoeuvre the ferry resulted in over-correction of steering, which led to the vessel swinging to port out of the channel, ultimately turning through 220°.
The subsequent collision and grounding occurred because the master lost his orientation in the fog and drove the ferry in the wrong direction. He became disorientated because he was suffering from cognitive overload due to high stress, lack of visibility, bridge equipment ergonomics, and the breakdown of support from the bridge team. The master’s actions and the lack of communication of his intent, resulted in the members of the bridge team becoming disengaged, and this led to an absence of any challenge to the master’s decisions.
Following its own investigations, Red Funnel has taken steps to improve its management processes, equipment and training routines, and Cowes Harbour Commission has undertaken a review of its aids to navigation and risk assessments.
Recommendations aimed at reducing the likelihood of future collisions and risk to harbour users have been made to Red Funnel, Cowes Harbour Commission and Cowes Yacht Haven.
Red Funnel has been recommended to conduct regular assessment of ship-handling capabilities including pilotage by instruments alone, and to review the shipboard method of determining orientation displayed on the ship’s electronic charting system. The Cowes Harbour Commission and the Cowes Yacht Haven have been recommended to review their risk assessments for collision between a commercial vessel and raft of yachts moored at their marinas detailing mitigating measures that are within their control to implement.
A statement from the Chief Inspector of Marine Accidents, said “Our investigation highlighted how quickly restricted visibility can negatively affect individuals’ awareness and orientation, which increases their stress and impacts on decision making. Crews on vessels of any size can be affected, but the consequences can be mitigated by prior preparation and training, effective teamwork, and a full understanding of the capabilities and limitations of the available instrumentation.
As a result of our investigation, Red Funnel has introduced measures to address many of the shortcomings identified in the report, but two recommendations have been made to the company aimed at further improving their operational practices.
It was very fortunate that nobody was on board yacht Greylag when it was struck and overrun by Red Falcon. In this respect, the family on a yacht on a nearby swinging mooring had a lucky escape. When Red Falcon swung around it narrowly missed Cowes Yacht Haven marina wall, and had yachts been rafted there the consequences of this accident could also have been much more severe. Our investigation has highlighted that commercial vessels can pose a danger to people sleeping on yachts in some areas of Cowes Harbour, and recommendations have been made to Cowes Harbour Commissioners and Cowes Yacht Haven to review their risk assessments.